Quality Manager Nurse Consultant - (Allentown, PA)

Telework Opportunity in Harrisburg, PA JOB DESCRIPTION Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation qualifications for member and/or provider issues. Position will support a post pay process for clinical reviews. Fundamental Components: Evaluates documentation/details to determine compliance with clinical policy, regulatory, and accreditation guidelines Accurately applies review qualifications to assure post pay reviews is reviewed based on clinical ability for the issue Knowledge of contracts (provider), clinical criteria, benefit plan structure, regulatory qualifications, company policy and other processes which are required to support the review of coding concepts and clinical info. Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines